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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200250
Report Date: 10/19/2021
Date Signed: 10/19/2021 01:48:15 PM

Document Has Been Signed on 10/19/2021 01:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:MCCLURE CARE HOMEFACILITY NUMBER:
019200250
ADMINISTRATOR:FEDERICO ROMERO/J. TABURFACILITY TYPE:
735
ADDRESS:2903 MCCLURE STREETTELEPHONE:
(510) 272-0104
CITY:OAKLANDSTATE: CAZIP CODE:
94609
CAPACITY: 25CENSUS: 23DATE:
10/19/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Normannelson LuatTIME COMPLETED:
02:05 PM
NARRATIVE
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On 10/19/2021, at 10:45AM, Licensing Program Analysts (LPAs) L. Francisco and C. Lin conducted a case management while at the facility for other matter. LPAs met with Administrator, Juliana Taburaza.

During the tour of facility with Care Staff, Normannelson Luat, LPAs observed an electrical power tool located by the garage was unlocked and accessible by clients. Deficiency cleared during visit. LPAs observed staff removed the electrical power tool and locked it away in the storage.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. Due to technical issue, LPAs will provide Appeal Rights and a copy of this report via email.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Catherine Lin
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/19/2021 01:48 PM - It Cannot Be Edited


Created By: Catherine Lin On 10/19/2021 at 01:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: MCCLURE CARE HOME
FACILITY NUMBER: 019200250

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2021
Section Cited
CCR
80087(g)

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80087 Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.
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Deficiency cleared during visit. Care Staff removed the eletrical power tool and locked it away in the storage.
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Based on observation, licensee did not comply with the regulation cided above. LPAs observed an electrical power tool was unlocked and accessible by clients which posed immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Catherine Lin
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2021


LIC809 (FAS) - (06/04)
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